Venous Ulcers

Question 1

Definition

Answer 1

Large, shallow, sometimes painful ulcers usually found superior to the medial malleoli. They are caused by incompetent valves in the lower limbs leading to venous stasis and ulceration.

Question 2

Aetiology

Answer 2

· They are caused by incompetent valves in the lower limbs

· Valve incompetence leads to venous stasis and increased venous pressure

· This results in ulceration

Question 3

Risk factors

Answer 3

o Obesity
o Immobility
o Recurrent DVT
o Varicose veins
o Previous injury/surgery to the leg
o Age

Question 4

Epidemiology

Answer 4

· VERY COMMON

· Increases with age

Question 5

Presenting symptoms

Answer 5

· Large, shallow, relatively painless ulcer with an irregular margin situated above the medial malleoli (most of the time)

· Features of the history:
o Varicose veins
o DVT
o Phlebitis
o Fracture, trauma or surgery
o Family history
o Other symptoms of venous insufficiency:
· Swelling
· Itching
· Aching

Question 6

Signs on physical examination

Answer 6

· Large, shallow, relatively painless ulcer with an irregular margin situated above the medial malleoli (most of the time)

· Other signs of venous ulcers:
o Stasis eczema
o Lipodermatosclerosis (inverted champagne bottle sign if SEVERE)
o Haemosiderin deposition (dark colour)

Question 7

Investigations

Answer 7

· ABPI
o Exclude arterial ulcer
o If ABPI < 0.8 - do NOT apply a pressure bandage as this could worsen the ulcer

· Measure surface area of ulcer - allows monitoring of progression

· Swabs for microbiology - if signs of infection

· Biopsy - if possibility of Marjolin’s ulcer

Question 8

Management plan

Answer 8

· Graduated compression (reduced venous stasis)
o NOTE: must exclude diabetes, neuropathy and PVD before this is attempted

· Debridement and cleaning

· Antibiotics - if infected

· Topical steroids - may help with surrounding dermatitis

Question 9

Possible complications

Answer 9

· Recurrence

· Infection

Question 10

Prognosis

Answer 10

· GOOD

· Results are better if patients are mobile with few comorbidities